Shoulder damage in a car crash

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During the last podcast I spent time talking about ligament damage.  More importantly I talked about objective evidence of ligament damage.  The last podcast covered 9 different outcomes that can be seen on x-rays to objectively show ligament damage. 

Today’s study continues the conversation of objective evidence for cervical ligament damage.  The article is Inter-examiner Reliability of Radiographic measurements from Open-Mouth Lateral Bending Cervical Radiographs.  The article was written by Karthik et al and published in the Chiropractic And Manual Therapies Journal in 2020. 

This study started by discussing if and how ligament damage is seen on imaging.  They reported that following trauma CT scans are often the imaging done to assess damage.  They showed that ligament injuries are often missed on CT scans in the spine.  More particularly this study looks into the cranio-cervical junction or upper cervical spine. 

This study addresses the definition and distinction between clinical instability and hypermobility.  Clinical instability as described by Panjabi and White is quote “loss of the ability of the spine under physiologic loads to maintain its pattern of displacement so that there is no initial or additional neurological deficits, no other major deformity, and no incapacitating pain” end quote.  Or in other words instability is when the spine under normal function cannot maintain so there is no nerve problems, deformities or incapacitating pain. 

Clinical hypermobility was described as quote “increased segmental motion ostensibly due to a sprain of the cervical ligaments, where the injury does not cause clinical instability but may cause persistent symptoms of neck pain and cervicogenic headache” end quote.  Or in other words hypermobility is often a ligament injury that doesn’t cause instability, but may cause persistent symptoms of neck pain and headaches. 

According to these definitions ligament damage alone is not enough to be called instability even with AOMSI.  For instability we need to have ligament damage and one of the following: nerve involvement, major deformity or incapacitating pain. 

This study was published the same year as the last podcast and the results from the last podcast’s study would not have been available when they wrote this study.  They reported that there is no reliable date to evaluate the upper cervical spine ligaments.  The study used for the last podcast did show 9 different types of measurements done on x-rays to assess for the upper cervical ligament damage. 

Today’s study looked at 56 patients who had open mouth lateral tilt x-rays taken.  These patients had persistent symptoms related to head and or neck trauma.  They looked into the inter examiner reliability to asses upper cervical ligament damage.  They used some of the same methods we discussed on the last podcast.  They looked into C1-2 lateral offset and peri-odontoid space symmetry and spinous process opposite side rotation with lateral flexion.

They showed that one difficulty with assessing upper cervical spine ligament damage is patient positioning.  There can be a lot of overlapping structures that interfere with these measurements.  There study showed that open mouth lateral flexion views can be an additional tool in evaluating upper cervical spine ligament damage.  They showed that offset of C1- on C2 greater than 1-2mm is an indicator of significant hypermobility of the upper cervical spine especially the alar ligament on the opposite side of the offset. 

This study reported that the open mouth lateral tilt views are good compliments to CT and MRI studies to evaluate ligament injuries in the cervical spine.  The odontoid lateral mass interspace was reported a good method to assess for occult or hard to find injuries such as fracture or subluxation. 

Assessment of the upper cervical spine ligaments is very important since it quote “has the greatest anatomic connection and neurologic cross-innervation with the head” end quote.  This study suggests that patients who have prolonged symptoms may have occult injuries of the upper cervical spine and that these types of injuries may be more frequent and often go unrecognized.  These types of injuries are quote “more frequent in the pediatric population where concussions are more frequent and symptoms are persistent” end quote. 

Real world

For my real-world example, I just did an IME for a local attorney on a young patient with persistent neck and headache pain.  Her x-rays showed that she did have AOMSI or the catastrophic ligament damage.  This is great objective evidence of serious ligament damage in her cervical spine which allows for a great impairment rating. 

This young patient also had the open mouth lateral flexion views.  These views showed large offset of C1 on C2 on both left and right open mouth lateral flexion.  This was more objective evidence of ligament damage in her cervical spine.  She had an MRI following the MVC that showed increased signal in the alar ligament which indicates damage to this ligament.  It was helpful to show that after care she continued to have the ligament damage and this was leading to abnormal function in her upper cervical spine. 

I now had multiple sources of objective evidence of ligament damage in her cervical spine.  This ligament damage correlated with her symptoms and ongoing neck and headache pain.  I was able to show and cite the literature showing that the findings on her x-rays and MRI would not be seen without ligament damage.  I covered how ligaments once damaged never fully heal and alter the function of the joints they surround.  This altered function will lead to degenerative osseous changes overtime.  These degenerative changes would take months to show up on imaging.  Given the lack of degenerative changes seen on her imaging this helps correlate the injury to her MVC. 

I was able to show the literature of what this type of injury will mean to the patient.  This type of injury will alter the ligament muscular reflex.  Her cervical spinal muscles will no longer have the ability to relax in low load situations and engage properly in high load situations.  Being a teenager she has a lot of life expectancy left.   She will need future care to manage these injuries.  The future care will be to slow the degenerative process of her injury, increase quality of life and decrease symptoms.  It is likely that with years of degenerative changes that she will need a future surgical consultation directly related to the MVC. 

This type of patient has a lifetime of care needed and a lifetime of symptoms ahead of her.  With proper management she should be able to have good quality of life, but will never make a full recovery.   Prior to her being sent to my office the attorney working her case was not getting any offers for settlement.  I am hoping that my report will show the insurance company that yes we have MRI and x-rays showing ligament damage and what this means for her life.

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